Treatment of osteomyelitis and the reconstruction of bone ... · Masquelet-technique Complete fullfilling of the defect with acrylic cement (mixed with antibiotics, overlapping the

Treatment of osteomyelitis and

the reconstruction of bone defects

Gerlach U-J

Department of Septic Trauma and Orthopedic Surgery

BG-Unfallkrankenhaus Hamburg

Ärztlicher Direktor: Prof. Dr. C. Jürgens

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Osteomyelitis

Septische Unfallchirurgie und Orthopädie

Trauma hospital with 745 beds

Largest speciality department in Germany for treatment of infections

of bone, soft tissue, joints and joint-replacements.

Departement of Septic Trauma and Orthopedic Surgery

- 102 beds (average number of daily in-house-patients)

- 1900 operations / y

- 5300 outpatients / y

Our patients: typically 5 operations before admittance

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Diseases we treat

- acute and chronic bone infections (osteomyelits) and

resulting problems

- acute und chronic joint infections and resulting problems

- infections of total joint replacements and resulting problems

- acute and chronic bone and joint infections due to diabetic foot

syndrom

- children with osteomyelitis

- soft tissue infections

- chronic wounds

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Resulting problems we treat:

- bone defects

- difference in extremity length (such as shortening of a leg)

- malposition of an extremity

- contracture of joints

- accompanying soft tissue defects

Also: prescription and/or checking of orthopedic devices (shoes, braces, prothesis)

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Particular patient patronage, special disease (due to trauma or complications after treatment).

If not treated correctly, the relapse rate will be high, the duration of the treatment much longer

with higher costs and bad outcome !!

The problem of an infection of the bone is commonly underestimated.

94% of our patients underwent unsuccessful treatment elsewhere before admitted to our hospital

with an average of 5 ineffective operations

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Combined: bone infection + instability + (very common) bone defect

And quite often:

- soft tissue defects

- nerval and/or blood circulation lesions

- problems caused by long lasting inactivity and lack of

movement

- reduced confidence

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The infection is caused by:

- number and virulence of the germs

- extent of the damage of the host

- co-morbidities of the patient

- iatrogenic factors

The developement of an infection is multifactorial

Implants – keyword biofilm

Osteomyelitis


© 2013 Nature Education All rights reserved Staphylococcus epidermidis

Foto: Janice Carr/ CDC/ Segrid McAllister

http://www.nature.com/nature_education

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Biofilm - implantats and bacteria

- the reproduction rate is clearly reduced

- covered by the biofilm the bacteria are less sensitive against antibiotics (factor 1000)

- covered by the biofilm the bacteria are safe against the body´s defenses

- the biofilm offers protection for chemical and mechanical impact

- higher resistance

- exchange of genetic informations

Chronic infections (implantat associated infections) are caues by bacterial biofilms !!

(Gristina u. Costerton 1985, Marie u. Costerton 1985, Anwar et al 1992, Costerton et al 1999, Gottenbus et al 2002, Parsek u.

Pingh 2003, Hall-Stoodley et al 2004, Zimmerli et al 2004, Lynch u. Robertson 2008; Costerton 2010)

Osteomyelitis


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Literatur: 1. Stemberger A, H Grimm, F Bader, HD Rahn, R Ascherl. „Local Treatment of Bone and Soft Tissue Infections with the Collagen-gentamicin Sponge.“ Eur J Surg Suppl 578 (1997): 17-26.2. Harris LG, RG Richards. „Staphylococci and implant surfaces: a review.“ Injury 37 (2006): 95-104.3. Vaudaux P, DP Lew. „Tolerance of staphylococci to bactericidal antibiotics.“ Injury 37 (2006): 15-19.4. Gristina AG, PT Naylor, QN Myrvik. „Musculoskeletal Infection, Microbial Adhesion, and Antibiotic Resistance.“ Infect Dis Clin North Am 4 (3) (1990): 391-408.5. Darouiche RO. „Treatment of infections associated with surgical implants.“ N Engl J Med 350 (14) (2004):1422-1429.6. Diefenbeck M, T Muckley, GO Hofmann. „Prophylaxis and treatment of implant-related infections by local application of antibiotics.“ Injury 37 (2006): 95-104.7. Lucke M, G Schmidmaier, S Sadoni, B Wildemann, R Schiller, NP Haas, M Raschke. „Gentamicin coating of metallic implants reduces implant-related osteomyelitis in rats.“ Bone 32 (2006): 521-531.8. Schmidmaier G, M Lucke, B Wildemann, NP Haas, M Raschke. „Prophylaxsis and treatment of implantrelated infections by antibiotic-coated implants: a review.“ Injury, Int. Care Injured37 (2006): 5105-5112.3/39. Luckea M, TB Wildemanna, S Sadonia, C Surkea, R Schillerb, A Stemberger, M Raschke, NP Haas, GSchmidmaier. „Systemic versus local application of gentamicin in prophylaxis of implant-related osteomyelitis in a rat model.“ Bone 36 (2005): 770- 778.10. Fuchs T, R Stange, G Schmidmaier, MJ Raschke. „The use of gentamicin-coated nails in the tibia:preliminary results of a prospective study.“ Arch Orthop Trauma Surg (2011) doi: 10.1007/s00402-011-1321-6.11. Raschke M, T Vordemvenne, T Fuchs. „Limb salvage or amputation? The use of a gentamicin coated nail in a severe, grade IIIc tibia fracture.“ Eur J Trauma Emerg Surg (2009)

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Infection rate post-trauma/ post-operative

following planed surgery: 0,1 – 1,7%

following operative therapy of fractures: 1 – 5 %

following operative therapy of open fractures: - 50%

Factors caused by the trauma:

- contamination of the wound/tissue

- squeezed soft tissue

- loss of tissue

- disturbance of the local perfusion

- colonization with germs

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The patient´s risk factors:

- age > 65 years

- obesity, malnutrition

- nicotine / alcohol dependency

- chronic diseases (cardio-vascular, allergies, circulatory disorder)

- Diabetes mellitus

- low immunity, immun-suppressive therapy

- rheumatic diseases

- accompanying infections (bladder, pneumonia..)

- damages caused by radiation

- catheter, artificial ventilation, hospitalization

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The surgeon as a risk factor:

- compromised local perfusion (surgical approach, retractor, rude operation technique)

- the implant

- intra-operative complications

- wrong indication

- point of time of the surgical intervention

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Primary goal of the therapy:

- long lasting stop of the infection

- closure of soft tissue defects

- reconstruction of bone defects

- stability of the extremity

- an extremity allowing full weight-bearing

- pain reduction

- professional reintegration

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Our therapy/our algorithm: al least 2-stage-surgery

1rst.operative step: treatment of the infection

2nd operative step: treatment of the soft tissue defects

3rd operative step: treatment of the bone defects

4th step: social and professional reintegration

Physiotherapy all the time!

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1st operative step:

- removal of every foreign body

- radical sequestrectomy

- implantation of local antibiotic carriers

- stabilization (external fixator)

- short term antibiotic therapy

Important for the successful therapy: radical sequestrectomy !

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2nd operative step:

Treatment of soft tissue defects

- as early as possible

- as stable as possible

- Co-operation with plastic surgeons in case of large defects

- Split skin, dermato-distraction, free flap

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Osteomyelitis


3rd operative step: Treatment of bone defects

- circular bone defect < 3,0cm:

transplantation of cancellous bone

- circular bone defect > 3,0cm:

segmental transport

- Masquelet technique

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21Septische Unfallchirurgie und Orthopädie

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Harvesting cancellous bone graft:

- posterior iliac crest

- anterior iliac crest

- tibial head

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Cancellous bone graft:

Typically, we add biomaterials to the cancallous bone graft in order to obtain a

local antibiotic carrier and/or osteoconductive materials:

- Gentacoll®, Sulmycin®, …..

- platelet rich plasma

- mesenchymal stemcelll concentrat

- Herafill Beads G®

- PerOssal®

- Cerament G®/V®

- BonAlive®

……

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Advantage: the resulting bone is similar to the original bone with the

same stability (hollow bone)

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Septische Unfallchirurgie und OrthopädieSeptische Unfallchirurgie und Orthopädie

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Masquelet-technique

Complete fullfilling of the defect with acrylic cement (mixed with antibiotics,

overlapping the bone-ends, intramedullar, soft-tissue-management)

Induced membrane:

- contains cells, which produce growth-faktors like bone morphogenic protein (BMP-2)

and transforming growth factor ß-1 (TGF ß-1) (Dumont et al 2008)

- revascularises bone graft and minimizes the resorbtion of bone graft

(Giannoudis et al 2011)

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Osteomyelitis


F.C., male 44 years

multiple trauma including craniocerebal injury, chest trauma, abdominal injury,

open fracture of the left femur and tibia, resulting dysphagia and aphasia

Development of an osteomyelitis of the femur and of the tiba left

Development of a chronic knee empyema left

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Debridement of both bones and the knee joint, stabilization with external fixator

femoral bone defect: 15,0 cm

multi-resistent Staph. epidermis, Serratia marscensens 3 MRGN

Reconstruction of the defect using Masquelet technique

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After 6 and 12 weeks cancellous bone graft from the the posterior iliac crest, combined with

PerOssal® and Vancomycin

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6 weeks later partial removal of the external fixator.

Then internal stabilization with a custom made angular stabil plate (Litos®) and cancellous bone

graft (left tibial head) combined with BonAlive®

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Osteomyelitis


Conclusion:

- The surgical treatment is decisive

- A radical removal of all infected bone and soft tissue has to be

performed

- Systemic and local antibiotic therapy supports the radical removal of

bone and soft tissue and is no substitute for incorrect surgical intervention

- The resulting defect is temporarely filled with antibiotic chains

(Septopal®) or bone cement

- Stabilization is necessary (external fixator)

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Osteomyelitis


Conclusion:

- No need to be afraid of the resulting defects! There are almost

always possibilities to reconstruct the bone

- In most cases the patients body offers the solution, biomaterials can be helpful

in reconstruction of the bone, especially in difficult cases

- The soft tissue defect and bone defect can to be treated in the majority of the

cases

- the bone reconstruction is a demanding therapy and should be performed in

specialized hospitals with experience in septic and reconstructive surgery

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Deckung HWT-Defekt durch Latissimus-Lappen, Einlage

Zementspacer, dann Segmenttransport.



Thank you for your attention !

Documents

Treatment of osteomyelitis and the reconstruction of bone ... · Masquelet-technique Complete fullfilling of the defect with acrylic cement (mixed with antibiotics, overlapping the